SHERIDAN SCHOOL DISTRICT DISTRITO ESCOLAR DE SHERIDAN STUDENT NAME: STUDENT ID # NEW STUDENT APPLICATION APLICACIÓN PARA NUEVOS ESTUDIANTES

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1 SHERIDAN SCHOOL DISTRICT DISTRITO ESCOLAR DE SHERIDAN ENGLISH. STUDENT NAME: STUDENT ID # Nombre del Estudiante # ID DEL ESTUDIANTE NEW STUDENT APPLICATION APLICACIÓN PARA NUEVOS ESTUDIANTES IN DISTRICT DENTRO DEL DISTRITO OUT OF DISTRICT FUERA DEL DISTRITO We must have the following BEFORE beginning school Necesitamos lo siguiente ANTES de comenzar la escuela.. Completed Application Aplicaciones Completadas Proof of Address (property bill/contract) Comprobante de Domicilio (pago o contrato de la propiedad) Birth Certificate Acta de Nacimiento Special Services/IEP (if applicable) Servicios Especiales/IEP (si es aplicable) Items needed within 30 days of enrollment Estos requisitos necesitan traerse entre los 30 días de estar inscrito. Immunizations Cartilla de vacunación Custody Papers if applicable Papeles de custodia si es aplicable Legal Requirements Regarding Public Notification of Civil Rights Regulations Sheridan School District is an equal opportunity educational institution and does not unlawfully discriminate on the basis of race, color, national origin, sex, or disability in admission or access to, or treatment or employment in, its educational programs or activities. Inquiries concerning Title VI, Title IX, Section 504 and ADA may be referred to the Special Education Director or Superintendent, 4000 S. Lowell, Sheridan, Colorado, 80236, (720) or to the Office for Civil Rights, U.S. Department of Education, Region VIII, Federal Office Building, 1244 North Speer Blvd., Suite 310, Denver, Colorado, 80204, (303) Requisitos Legales con Referencia a la Notificación Pública sobre Reglamentos de Derechos Civiles. El Distrito Escolar Sheridan No. 2 es una institución educativa que da igual oportunidad y no discrimina por razones de raza, color, origen nacional, sexo, ni niega a estudiantes impedidos/incapacitados a ser admitidos, a recibir acceso a tratamiento, empleo mediante programas educativos o actividades que ofrece la escuela. Cualquier investigación referente al Título VI, Título IX, Sección 504 y ADA puede realizarse mediante el Director de Educación Especial o el Superintendente, 4000 So. Lowell, Sheridan, Colorado, 80110, (720( De otra manera pueden presentarse en la oficina de Derechos Civiles, Departamento de Educación, Región VIII, Edificio de Oficinas Federales, 1244 North Speer Blvd., Suite 310, Denver, CO 80204, (303)

2 SHERIDAN SCHOOL DISTRICT STUDENT REGISTRATION FORM DISTRITO ESCOLAR DE SHERIDAN FORMA DE INSCRIPCION PARA ESTUDIANTES EARLY CHILDHOOD CENTER ALICE TERRY ELEMENTARY SHERIDAN MIDDLE SCHOOL SHERIDAN HIGH SCHOOL FORT LOGAN ELEMENTARY Grade Entering Grado al que Ingresa Student s Legal Name: Nombre del Estudiante (Last) Apellido (First) Nombre (Middle) 2do nombre Gender (M/F) Birth Date: Place of Birth: Sexo Fecha de Nacimiento Lugar de Nac. (City) Ciudad (State or Nation) Edo. o Pais Please answer BOTH of the following questions. REQUIRED MUST CHECK ONE of the following Ethnicities: DEBEN MARCAR UNA de las siguientes categorías étnicas Hispanic or Latino (Hispano o Latino) Not Hispanic or Latino (No Hispano o Latino) REQUIRED MUST CHECK ONE OR MORE that apply POR FAVOR MARQUEN UNO O MAS a las que aplican Racial categories: Categorias Raciales: American Indian or Alaskan Native (Indio Americano o Nativo de Alaska) Asian (Asiático) Black or African American (Negro o Afro Americano) White (or of Spanish origin) Blanco (o de origen hispano) Native Hawaiian or Other Pacific Islander (Nativo Hawaiano o de otras Islas del Pacifico) School transferring from: City and State Escuela de donde es Transferido Ciudad y Estado How many consecutive years has student been enrolled in US? What month and year? in Colorado? What month and year? Cuántos años consecutivos ha estado su niño inscrito en una escuela en Estados Unidos? Mes y año en Colorado? Mes y Año Has your student attended Sheridan Schools in the past? Yes No Is this student a refugee? Yes No Su estudiante ha asistido a las escuelas de Sheridan en el pasado? Si No Es un estudiante refugiado? Si No Has student ever been enrolled in Special Education/Gifted & Talented programs? Yes No Su estudiante ha estado inscrito en un programa de Educ. Especial o para Niños Dotados? Si No If Yes, which one? Special Ed. (IEP) G/T 504 Reading Program Si contesto Si, en cual? Educ. Especial (IEP) G/T 504 Programa de Lectura

3 Household Address: Domicilio de la Familia (Number) Numero (Street) Calle (Apt #) (City) Ciudad (State) Estado (Zip) Código Postal Main Phone: Número de Teléfono Principal Parent/Legal Guardian Demographic Data Datos Demográficos del los Padres/Tutores Legales Adult Name (Nombre del adulto): Relationship (Relación): Employer (Lugar de Trabajo): Work Phone (Teléfono del Trabajo): Cell Phone (Teléfono Celular): Address (Dirección Electrónica): Adult Name (Nombre del Adulto): Relationship (Relación): Employer (Lugar de Trabajo): Work Phone (Teléfono del Trabajo): Cell Phone (Teléfono Celular): Address (Dirección Electrónica): Marital Status: Married Divorced Separated Single Widow Estado Civil Casado Divorciado Separado Soltero Viudo Student Resides With: El Estudiante Vive con: Both Parents (Ambos Padres) Father Only (Solo con el Padre) Legal Guardian (Tutor Legal) Mother Only (Solo con la Madre) Father & Stepmother (Padre y Madrastra) Foster Parent (Padres Adoptivos) Mother & Stepfather (Madre y Padrastro) Other Relative (Otro Familiar) Emancipate / Independent Student (Emancipado/Estudiante Independiente) Please give names of all other adults living in the home if different from mother and father listed above: Por favor, anote los nombres de otros adultos que viven en la casa aparte de la madre y padre nombrados arriba All Children Living in Household School Attending Age All Children Living in Household School Attending Age Todos Niños que viven en casa Escuela que Asisten Edad Todos Niños que viven en casa Escuela que Asisten Edad Emergency Contact (Contacto de Emergencia): Emergency Contact (Contacto de Emergencia): Phone (Teléfono): Phone (Teléfono): Name(s) of person(s) other than parent and/or Emergency Contact(s) to whom the student may/may not be released (Please provide documentation for persons who may not pick up student): Nombre(s) de persona(s) aparte de los padres y/o o Contacto de Emergencia que pueden/no pueden recoger al estudiante. (Por favor, muestre documentación sobre las personas que no pueden recoger a un estudiante) 1. (May / May Not) 2. (May / May Not) (Puede/No puede) (Puede/No puede) 3. (May / May Not) 4. (May / May Not) (Puede/No Puede) (Puede/No puede) Failure to completely and truthfully answer all above questions may result in removal from school. I certify the answers to the above questions are up-to-date, accurate, and complete. El no responder completamente y con la verdad a todas las preguntas puede resultar en la restitución del estudiante de la escuela. Certifico que las respuestas a las preguntas de la parte de arriba están actualizadas, precisas y completas. Parent Signature Firma de los Padres Date Fecha

4 Sheridan School District No. 2 Alice Terry Elementary School P.O. Box S. Irving St. Englewood, CO Englewood, CO AUTHORIZATION TO RELEASE RECORDS To (Previous School).. Phone:. Fax:. It is requested that an official copy of the records of the listed student be released: Student's Name: DOB: Grade Records to be released: Official Administrative Records (Cum. File) Birth Certificate Please send records to: Grades/Transcripts Standardized Test Scores Intelligence and Aptitude Test Scores Health Data/Immunizations/Information Family Background Information Educational Evaluation Psychological Evaluation Teacher/Counselor Observation and Ratings Other Pertinent Information Alice Terry Elementary School 4485 S. Irving St. Sheridan, CO Phone: Fax: ****************************************************************************** I hereby give my permission for the release of the above indicated records. Parent Signature Date LEGAL REF.: U.S.C. 1232G (Family Educational Rights and Privacy Act)

5 ALICE TERRY ELEMENTARY SCHOOL PERMISSION TO PUBLISH Student s Name: Date: I give permission for Alice Terry to publish my child s work and/or my child s picture. This may include the school newsletter, on the Sheridan website, and local or national publications. Parent / Guardian Signature HANDBOOK/CODE OF CONDUCT The Alice Terry Elemenary Handbook is now located on the Sheridan School District Web Site. I am responsible for reviewing the rules and behavioral expectations with my student. This includes the attendance policy. You may request a copy from the school office. Parent / Guardian Signature PARENT/GUARDIAN STATEMENT Please check the appropriate box: My child has not been expelled from any school district during the preceding 12 months and has not engaged in behavior in another school district during the preceding 12 months that was detrimental to the welfare or safety of other student or of school personnel. My child has been expelled from a school district during the preceding 12 months, and/or has engaged in behavior in another school district during the preceding 12 months that was detrimental to the welfare or safety of other student or of school personnel. Parent/Guardian Signature: FIELD TRIP FORM I give permission for my son/daughter, to participate in a field trip to any of the schools within Sheridan School District. Parent and child understand that the above stated field trip forms a part of the child s educational experience and constitutes an extension of his/her school program in accordance with Sheridan School District Policy. In order, for your child to participate, this permission slip must be returned with a parent s signature and the medical release at the bottom of the page MUST be filled out completely. Please be advised, that those students who are not in good behavioral standing in their classes, may be required to forgo this field trip and are required to attend school. Parent/Guardian Signature: PERMISSION FOR MEDICAL TREATMENT If you are not able to communicate with me or my student s emergency contacts, I authorize professional, reasonable emergency medical attention to ensure the health of my student. Parent/Guardian Signature:

6 SHERIDAN SCHOOL DISTRICT MEDICAL TREATMENT RELEASE & INSURANCE INFORMATION IMPORTANT: FORM MUST BE FILLED OUT COMPLETELY IN ORDER FOR STUDENT TO ATTEND SCHOOL Student Name: Grade: Date Of Birth (Please Print) Parent/Guardian Name: Home# Wk# Parent/Guardian Name: Home# Wk# Emergency Name: Phone# INSURANCE INFO: Name of Policy Holder No Insurance MEDICAID # Private Insurance CHP Insurance Company Policy Number (Name of Insurance Company if other than Medicaid) Primary Physician Phone Hospital Preference Colorado school districts are entitled by law to seek Medicaid reimbursement when health services are delivered to Medicaid eligible students. School Medicaid reimbursement does not affect the family s other Medicaid benefits in any way. I give consent and authorize the Sheridan School District to release to Colorado Health Care Policy and Financing (HCPF) information related to Medicaid-eligible services delivered to my child, if/when my child is enrolled in the Medicaid program. I do not wish to give consent for Medicaid billing (see above for explanation) IMMUNIZATION INFORMATION RELEASE I give permission for exchange of information between my child s physician and the Sheridan School District for the purpose of establishing documentation of current immunization status. Date Parent/Guardian or Emancipate Student Signature Health Problems (Past and Present) Has your child ever experienced or is your child currently experiencing any of the following conditions? Please mark the proper column. None Condition Past Present Condition Past Present Condition Past Present Allergies Asthma Diabetes ADD/ADHD Heart Problems Ear Infections Seizure Disorder Blood Problems Vision Problems Bladder Problems Orthopedic Problems Neurological problems Emotional Problems Significant Injury Other (explain) Hearing Impaired Physical Disability Other (explain) Kidney Problems Hospitalization Please explain items marked in more detail. List Allergies Please list the name and dose of any medication(s) the student takes on a regular basis. All prescription and over the counter medications given at school require a completed medication permission form with health care provider and parent/guardian signatures. If parent or guardian cannot be contacted, we, the undersigned parents/guardians of the child identified above, hereby authorize officials of the Sheridan School District #2 to contact directly the following physicians of our selection, and we hereby certify that we are the parents/guardians of said minor child, and do authorize the physicians named above to render such treatment as said physician, or either of them, may deem reasonably necessary, in an emergency, for the health of said child, without further authorization than here expressed. In the event neither of the physicians here named can be contacted, or either of us is unavailable to give our express consent at such time with reference to any other physician, we hereby consent and authorize the officials of the School District to contact any licensed physician, and we hereby authorize said physician to render such treatment as he may deem reasonably necessary, in what he may consider to be an emergency, for the health of our aforesaid minor child. Expense incurred, as a result of emergency ambulance use or treatment by physician will not be borne by the school or school personnel. Standard emergency procedure in cases where injury could be serious is to call Sheridan Fire Department Paramedic Unit for assistance. Parent/Guardian or Emancipate Student Signature Date

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